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\begin{document}

\title{Permanent pacemaker implantation in a hemodialysis patient with
subclavian vein occlusion using the balloon-target puncture technique}



\author[1]{Yuhei Kasai}%
\author[1]{Sandeep Shakya}%
\author[1]{Takashi Yamaura}%
\author[1]{Naoki Hayakawa}%
\author[1]{Kotaro Miyaji}%
\author[2]{Junji Kanda}%
\affil[1]{Affiliation not available}%
\affil[2]{Asahi General Hospital}%


\vspace{-1em}



  
  \date{June 08, 2024}


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\selectlanguage{english}
\begin{abstract}
We describe a case of permanent pacemaker implantation in a 59-year-old
male with subclavian vein occlusion undergoing hemodialysis. The
balloon-target puncture technique aided successful and safe transvenous
permanent pacemaker implantation.%
\end{abstract}%



\sloppy


\textbf{Permanent pacemaker implantationin a hemodialysis patient with
subclavian vein occlusion using the balloon-target puncture technique}

Yuhei Kasai, Sandeep Shakya, Takashi Yamaura, Naoki Hayakawa, Kotaro
Miyaji, Junji Kanda

Department of Cardiology, Asahi General Hospital, Chiba, Japan

Correspondence to: Dr. Yuhei Kasai, MD

Asahi General Hospital, 1326, I, Asahi-city, Chiba 289-2511, Japan

Tel: +81-479-63-8111; Fax: +81-479-62-8383

Email: yuheikasai\_1025@yahoo.co.jp



\textbf{ABSTRACT}

We describe a case of~permanent pacemaker~implantation in a 59-year-old
male with subclavian vein occlusion undergoing hemodialysis. The
balloon-target puncture technique aided successful and safe transvenous
permanent pacemaker implantation.

\textbf{KEYWORDS}

subclavian vein occlusion, balloon-target puncture technique, permanent
pacemaker implantation, hemodialysis, carbon dioxide digital subtraction
angiography

\textbf{KEY CLINICAL MESSAGE}

The balloon-target puncture technique is an effective method to secure
the subclavian vein access route of cardiovascular implantable
electronic devices.

\textbf{1 \textbar{} INTRODUCTION}

The most widely used method for permanent pacemaker implantation (PMI)
is via the subclavian vein. In patients undergoing hemodialysis,
subclavian vein occlusion is common. A previous report described that
venous stenosis or occlusion are observed in 10\% of patients undergoing
hemodialysis with no history of catheter placement.\textsuperscript{1}In
such patients, permanent PMI can be challenging; thus, endovascular
treatment (EVT) may be necessary.

Herein, we describe a case of~EVT for subclavian vein occlusion and
permanent PMI in a 59-year-old male undergoing hemodialysis. EVT was
performed using the balloon-target puncture technique as an alternative
technique for lead implantation. To the best of our knowledge, this is
the first report of balloon-target puncture as an alternative technique
for lead implantation.

\textbf{2 \textbar{} CASE REPORT}

The patient was a 59-year-old male with a 12-year history of
hemodialysis due to diabetic kidney disease. The patient had a history
of failed bilateral arteriovenous fistula and underwent placement of an
arteriovenous graft in his left arm 2 years ago for hemodialysis. The
patient experienced syncope during hemodialysis. Electrocardiography
showed complete atrioventricular block and was transported to our
hospital for further treatment. Temporary PMI was immediately performed
via the right internal jugular vein, and the patient was admitted for
permanent PMI the following day.

Permanent PMI was planned in the right chest because of presence of the
graft in the left arm. Right subclavian venography was not performed
because the patient had experienced an allergic reaction to iodinated
contrast 2 years prior. Instead, we decided to introduce a 0.035-inch
guidewire into the right subclavian vein (SCV) for puncture.

During the procedure, a 5-Fr sheath was inserted from the right femoral
vein. A 0.035-inch Radifocus wire\selectlanguage{ngerman}\textsuperscript{®} (Terumo, Tokyo,
Japan) with the support of a 4-Fr Judkins right (JR)
catheter\textsuperscript{®} (Medikit, Tokyo, Japan) was introduced.
However, we could not pass the guidewire to the right SCV. Thus, SCV
occlusion was suspected. Carbon dioxide digital subtraction angiography
(CO\textsubscript{2}-DSA) was performed using the JR catheter at the
right brachiocephalic vein (Figure 1A), which showed total occlusion of
the right SCV. To determine occlusion length, venography from the
basilic vein was performed. A 5-Fr sheath was inserted into the right
basilic vein using ultrasound-guided puncture. The 0.035-inch Radifocus
wire was inserted with the support of a 4-Fr
Glidecath\textsuperscript{®} (Terumo, Tokyo, Japan). The guidewire
successfully passed to the distal end of the SCV, and
CO\textsubscript{2}-DSA was performed (Figure 1B).

Since the patient had a graft in the left arm and a prior history of
failed bilateral arteriovenous fistula, a transvenous pacemaker was
implanted on the right side. A leadless pacemaker was an alternative
option, but because of a prior allergic reaction to iodinated contrast,
there was a risk of developing an allergic reaction. The occlusion
length was short, so EVT to the right SCV was decided.

A 0.014-inch guidewire
(Gladius\textsuperscript{®}Mongo\textsuperscript{®} PV ES; Asahi Intecc,
Nagoya, Japan) with the support of a 4-Fr Glidecath was introduced via
the right basilic vein and penetrated the occlusion successfully before
being advanced into the superior vena cava. A 5.0 × 40-mm
Mustang\textsuperscript{®} balloon (Boston Scientific, Massachusetts,
USA) could not pass the occlusion. We predilated the lesion using a 2.0
× 40-mm Coyote\textsuperscript{®}followed by a 4.0 × 40-mm Coyote
(Boston Scientific, Massachusetts, USA). Using the Glidecath, we changed
the Gladius Mongo PV ES to a 0.035-inch Radifocus wire. The 5.0 × 40-mm
Mustang passed the lesion, and balloon angioplasty was performed. Then,
we used a 21-G micro-puncture needle (Cook, Tokyo, Japan) to puncture
the right SCV. However, puncture was not successful as venous blood
could not be drawn. Vein elastic recoil was considered, and we decided
to puncture the balloon instead.

The 5.0 × 40-mm Mustang was dilated in the SCV. Using a 21-G
micro-puncture needle attached to a 2.5-ml syringe, we punctured the
balloon under the guidance of fluoroscopy. On successful puncture,
almost all diluted contrast was aspirated into the syringe (Figures 2A,
B). The guidewire was inserted; however, the guidewire alone could not
pass into the vein, and both the balloon and guidewire were pushed.
Subsequently, the guidewire was successfully advanced into the SCV
(Figures 2C, D, E). This sequence of procedures is named the
balloon-target puncture technique.

We used the one-puncture two-sheath technique to introduce two 7-Fr
peel-off sheaths (Medikit, Tokyo, Japan) into the SCV and successfully
implanted the pacemaker (Figure 2F). The
SelectSecure\selectlanguage{english}\textsuperscript{}MRI SureScan\selectlanguage{english}\textsuperscript{} lead
(Medtronic, Dublin, Ireland) was implanted using a C315 S10 guiding
catheter into the right ventricular septum, and the CapSureFix Novus
MRI\selectlanguage{english}\textsuperscript{} SureScan screw-in lead was implanted into the
right atrial appendage. The procedural duration was 2 hours 25 minutes,
and the fluoroscopy time was 36 minutes. No perioperative complications
occurred. The patient was discharged after 1 week.

\textbf{3 \textbar{} DISCUSSION}

The subclavian route is commonly used for insertion of cardiovascular
implantable electronic devices. However, in the presence of subclavian
vein occlusion, this route cannot be used. To circumvent this issue, a
number of venous system interventions for cardiovascular implantable
electronic device implantation have been reported.\textsuperscript{2,
3}However, to the best of our knowledge, there have been no reports on
how to puncture the SCV safely after SCV recanalization. Herein, the
balloon-target puncture technique, which can achieve safe puncture, was
used in a 59-year-old male undergoing hemodialysis with SCV occlusion.

This technique has some advantages. First, it is effective in cases of
elastic recoil after balloon angioplasty. In this case, we tried to
puncture the SCV using a 21-G micro-puncture needle toward the
0.035-inch Radifocus, but this method was unsuccessful despite three
attempts at puncture. At first, the 5.0 x 40-mm Mustang balloon could
not pass the occlusion. Subsequently, we predilated the lesion using a
2.0 x 40-mm Coyote followed by a 4.0 x 40-mm Coyote using a method
termed stepwise balloon angioplasty. Despite stepwise balloon
angioplasty, it remained difficult to pass a 5.0 x 40-mm Mustang through
the lesion, which suggested elastic recoil of the puncture lesion after
balloon angioplasty. Therefore, puncturing the dilated balloon of the
elastic recoiled lesion was a reasonable approach to take.

Second, this technique makes it possible to puncture all regions of the
SCV away from the ribcage. Normally, we puncture the SCV above the
ribcage to prevent pneumothorax. With this technique, the need for the
Seldinger method is significantly reduced. Therefore, we do not
necessarily have to puncture the SCV above the ribcage.

Third, this technique suggests that we should not puncture lesions
refractory to balloon dilatation. Jose et al. reported that
approximately 3\% of patients who require EVT for the SCV have a lesion
refractory to an ultra-non-compliant balloon (rated balloon pressure: 30
atm).\textsuperscript{3} In this case, fortunately, there were no SCV
lesions refractory to non-compliant balloon dilatation. If possible, we
should puncture proximal to the lesion refractory to balloon dilatation
to reduce damage to cardiovascular implantable electronic device leads.

Finally, this technique can be used in patients who require addition or
replacement of cardiovascular implantable electronic device leads. The
incidence of SCV stenosis or occlusion after device implantation varies
widely in the literature (ranging from 25\% to
50\%\textsuperscript{5-8}); however, situations in which this technique
should be used are not uncommon.

To perform the balloon-target puncture technique, we need no additional
balloons and catheters for patients with transvenous cardiovascular
implantable electronic devices who require EVT. When SCV puncture using
conventional puncture methods, such as guidewire or contrast-guided
methods, is difficult, the balloon-target puncture technique should be
actively used as a cost-effective option.

\textbf{4 \textbar{} CONCLUSION}

The balloon-target puncture technique could be useful during intravenous
permanent PMI requiring SCV intervention.

\textbf{AUTHOR CONTRIBUTIONS}

YK wrote the manuscript and was the second EVT operator and the first
PMI operator. SS supervised the writing of the manuscript and was the
first EVT operator and the second PMI operator. TY assisted both EVT and
PMI. NH supervised the EVT procedure. KM supervised the PMI procedure.
JK supervised the project. All authors read and approved the final
manuscript.

\textbf{ACKNOWLEDGMENTS}

We thank Edanz Group (https://en-author-services.edanzgroup.com/ac) for
editing a draft of this manuscript.

\textbf{CONFLICT OF INTEREST}

None declared.

\textbf{ETHICAL APPROVAL}

The enrolled patient provided written informed consent. The examination
was made in accordance with the approved principles. All the
preparations and the equipment used are officially certified for the
clinical use.

\textbf{DATA AVAILABILITY STATEMENT}

Data are available on request.

\textbf{REFERENCES}

1. Oguzkurt, L., Tercan, F., Yildirim, S., et al. Central venous
stenosis in haemodialysis patients without a previous history of
catheter placement. Eur J Radiol. 2005;55:237-242.

2. Dante, A., Nahum, A. F., and Yoav, T. Supraclavicular vein approach
to overcoming ipsilateral chronic subclavian vein obstruction during
pacemaker--ICD lead revision or upgrading. Europace. 2010;12:1596-1599.

3. Yousef, Z., Paul, V., and Leyva, F. Cardiac resynchronization via the
femoral vein: a novel method in cases with contraindications to the
pectoral approach. Europace. 2006;8:144-146.

4. Jose, M. M., and Seth, J. W. Venous system interventions for device
implantations. Card Electrophysiol Clin. 2018;10:163-177.

5. Antonelli, D., Turgeman, Y., Kaveh, Z., et al. Short term thrombosis
after transvenous permanent pacemaker insertion. Pacing Clinical
Electrophysiol. 1989;12:280-282.

6. Goto, Y., Abe, T., Sekine, S., et al. Long-term thrombosis after
transvenous permanent pacemaker implantation. Pacing Clin
Electrophysiol. 1998;21:1192-1195.

7. Lickfett, L., Bitzen, A., Arepally, A., et al. Incidence of venous
obstruction following insertion of an implantable cardioverter
defibrillator. A study of systematic contrast venography on patients
presenting for their first elective ICD generator replacement. Europace.
2004;6:25-31.

8. Haghjoo, M., Nikoo, M. H., Fazelifar, A. F., et al. Predictors of
venous obstruction following pacemaker or implantable
cardioverter-defibrillator implantation: a contrast venographic study on
100 patients admitted for generator change, lead revision, or device
upgrade. Europace. 2007;9:328-332.

\textbf{Figure legends}

\textbf{Figure 1A.} CO\textsubscript{2}-DSA performed at the right
brachiocephalic vein. CO\textsubscript{2}-DSA, carbon dioxide digital
subtraction angiography.

\textbf{Figure 1B.} CO\textsubscript{2}-DSA performed at the distal end
of the subclavian vein. CO\textsubscript{2}-DSA, carbon dioxide digital
subtraction angiography.

\textbf{Figure 2A.} When a 5.0 x 40-mm Mustang was dilated in the SCV,
we attempted to puncture the balloon with a micro-puncture needle. SCV,
subclavian vein.

\textbf{Figure 2B.} Because of balloon puncture, the diluted contrast in
the balloon was aspirated into the syringe, which revealed that the
micro-puncture needle tip was in the SCV. SCV, subclavian vein.

\textbf{Figures 2C, D.} Both the balloon and guidewire were pushed. The
guidewire was advanced in the same way as a knuckle wire technique in
the same way as a knuckle wire technique.

\textbf{Figure 2E.} The guidewire was successfully advanced into the
SCV. SCV, subclavian vein.

\textbf{Figure 2F.} A dual-chamber pacemaker was implanted. The atrial
lead was implanted into the right atrial appendage, and the ventricular
lead was implanted into the right ventricular septum.

\textbf{Hosted file}

\verb`Figure.pptx`  available at \url{https://authorea.com/users/360894/articles/514089-permanent-pacemaker-implantation-in-a-hemodialysis-patient-with-subclavian-vein-occlusion-using-the-balloon-target-puncture-technique}

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